Healthcare Provider Details

I. General information

NPI: 1265654099
Provider Name (Legal Business Name): LAKE COUNTY PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 BROADWAY STE E
MERRILLVILLE IN
46410
US

IV. Provider business mailing address

8500 BROADWAY STE E
MERRILLVILLE IN
46410
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-9580
  • Fax: 219-736-9581
Mailing address:
  • Phone: 219-736-9580
  • Fax: 219-736-9581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01025495
License Number StateIN

VIII. Authorized Official

Name: CONSTANCIO B ACOSTA
Title or Position: PHYSICIAN PEDIATRICIAN
Credential: MD
Phone: 219-736-9580